Friday, 11 January 2013

POVERTY: Zimbabwe: Morphine Kills Pain but its Price Kills Patients

The Bulawayo Island Hospice has been operating since 1982 and is one of the few medical facilities catering to Zimbabwe’s poor. Credit: Busani Bafana/IPS

BULAWAYO, Jan 11 2013 (IPS) - It took Gily Ncube’s daughters two weeks to sell enough chickens to raise the 18 dollars needed to buy the morphine tablets their mother takes every four hours.

In a country where unemployment is estimated at 70 percent, 18 dollars for a bottle of 60 tablets of 10 milligrammes (mg) each is a steep price to pay, equivalent to about 18 loaves of bread.

But the small, rural family had no choice – morphine is the only drug that eases Ncube’s pain so she can get to sleep at night.

Ncube (not her real name) has stage four cancer of the cervix and is now almost completely bedridden. Even more than treatment, she desires some relief from the pain brought on by her condition.

Morphine, a controlled drug derived from opium, provides Ncube and other patients like herself a little comfort. A daily dose of about 40 mg enables Ncube to sit up, even do a few chores around the house.

But at current prices, few can afford the drug, or access it when needed.

Pain is scrawled all over Ncube’s face as she narrates her tale: for six months now she has been on the waiting list to undergo radiotherapy at Mpilo Hospital in Bulawayo, Zimbabwe’s second largest city, located about 430 kilometres southwest of the capital Harare.

The radiotherapy machine has been broken for longer than she has been waiting and a new one is only now being installed.

“The pain is unimaginable,” Ncube told IPS in her home. Pointing to a white plastic bottle filled with paracetamol, a mild painkiller, she added, “That is all I could get from the hospital.”

Still, of the roughly 7,000 cancer patients in the country, Ncube is one of the lucky ones – she receives help, and sometimes a supply of morphine, from the Bulawayo Island Hospice that has been operating here since 1982.

Hospice officials told IPS that the health system is so inadequate many of their patients have died awaiting an oncologist’s appointments, often suffering severe pain at the end despite having a prescription for morphine.

Sister Adelaide Nyathi, who works for the Bulawayo Island Hospice Service, has more than 90 cancer patients under her care. She makes weekly visits to check on them, bringing pain killers and bits of food when she can, but mostly smiles, hugs, and hope.

Nyathi said the hospice service relies on donated morphine to offer some respite to scores of suffering patients.

“Most of our patients are at an advanced stage of cancer where non-opiate drugs make no difference to the pain,” Nyathi told IPS. “Patients have told me that they try to get used to the pain but it is never easy.”

Though the Zimbabwe government has estimated about 7,000 cancer patients in the country, caregivers say the actual number of cases could be far higher, since many patients die before they are even diagnosed.

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Services are incredibly limited, and now one of the few alternatives left to poor people – the Bulawayo Island Hospice, one of the oldest in Zimbabwe – is at risk of closure due to high operating costs and low donor support.

The hospice has just five nurses who look after nearly 200 cancer patients throughout the city, whom they visit each week. While they are able to bring some relief, they cannot save every patient in dire need.

Sekesai Dziva (not her real name) was diagnosed with throat cancer in 2010 and endured many hardships. Her sons worked round the clock to raise 84 dollars to buy the chemotherapy tablets that just barely kept her alive.

But often the money ran out and during those periods she would lie in a daze of pain for days on end. She died six months ago, leaving behind three teenage children.

Although morphine tablets and injections are manufactured in Zimbabwe, the cost is still prohibitive for many patients, a situation one health expert believes could be rectified with the use of liquid (mist) morphine, made from morphine powder, which pharmacy technicians and even nurses can be trained to prepare and manufacture at local health institutions.

“We know many patients cannot afford to buy morphine tablets because 18 dollars is a lot of money,” Head of the Island Hospice Service in Harare, Dr. Dickson Chifamba, told IPS. “That 18 dollars could translate into more than 54 dollars per month, even for someone on a low dose of one tablet (10 mg) every four hours.”

“Liquid (mist) morphine is a good option if we can have health workers trained in preparing it from the morphine powder,” Chifamba said. “Pharmacists can do it but often lament that it is time consuming.”

Efforts are currently underway to engage local and external partners to help train health personnel, mainly technicians in local health institutions, to manufacture liquid morphine.

“The liquid form will make (the medication) cheaper; it is also more convenient to distribute through government hospitals,” he added.

According to the Medicines Control Authority of Zimbabwe (MCAZ), hospitals and pharmacies are allowed to stock morphine powder for making the liquid preparations, which is cheaper and convenient for patients too ill to take tablets.

In collaboration with the International Narcotics Control Board (INCB), the MCAZ compiles and analyses national usage statistics in order to allocate a quantity of morphine for distribution throughout Zimbabwe annually.

Last year, according to MCAZ Director General Gugu Mahlangu, Zimbabwe used a total of 3.6 kilogrammes of morphine, despite being allocated 11.25 kilogrammes for 2012.

Mahlangu added that the use of pain alleviating medicines such as morphine is very low in Africa, with the exception of South Africa, compared to the rest of the world.

According to the World Health Organisation (WHO), about 4.8 million people with severe cancer pain go untreated annually. The INCB revealed that developed countries consume nearly 80 percent of the world’s morphine, with developing countries sharing the balance between them.

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After service in the British SAS Regiment the author became a physician and then an orthopaedic surgeon.
He has held professorial positions in Canada, Vietnam and the United States, practiced and taught orthopaedic surgery in three continents and in several wars.
He has extensive experience as an expert witness in court. Somewhere along the way, time was found to operate a four hundred acre mixed farm, a one hundred seat restaurant and to obtain a licence as a flying instructor.
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